“The U.S. health care delivery system does not provide consistent, high quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” – From the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century
In a recent well thought out blog post, Alex Fair asks the question – is healthcare too important to fail?
He discusses the precarious balance between disrupting healthcare and the ongoing need to preserve the care delivery system so the community can continue to benefit from services. Rightfully so, he outlines two tenants for an Occupy Healthcare movement:
1. Do No Harm, do not disrupt the delivery system
2. We all must Embrace Innovation that Reduces the Cost of Delivering or Receiving Care
However, here is the fundamental question – a question that is at the heart of any and all who are interested in changing healthcare – where do we draw the line between the system and the care delivered? Is it possible? Can we be assured that disrupting the system will never happen if we want to see substantive change?
According the the IOM report, healthcare is failing. And this failing is not small (a gap), it is quite significant (a chasm).
Gawande has an excellent take on healthcare change. From his article in the New Yorker: “Whatever the [healthcare] system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation—which is to say, a health-care system that works. And there are ways to get there that start from where we are.”
My point here is to tie together both what Alex said in his blog, and what Gawande said in his article – there are ways to transform healthcare, but where is the right level of disruption that pushes us forward, keeping all the good things and preserving pieces of the system that can continue to meet the healthcare need of the community while ridding ourselves of the parts that don’t work?
Often our failing can be attributed to perverse system incentives and demands. Healthcare providers behavior is often dictated by the system. Take for example services recommended by the US Preventive Services Task Force (USPSTF). No doubt these recommendations are important and need to be addressed; however, in a healthcare system that is often driven by time, it is seemingly impossible to do all that is recommended.
Consider the now highly cited Yarnell paper from the American Journal of Public Heath:
“To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.”
Bending the cost curve in healthcare requires addressing several things simultaneously. Prevention is one of those things.
“Disease prevention initiatives aimed at improving nutrition, physical activity, tobacco use, and related lifestyle behaviors are likely to have the greatest effect on slowing the annual increase in health care costs. This is because they have the largest influence on reducing the future burden of disease, particularly in regard to obesity and the sequelae of diabetes, heart disease, and cancer.”
This brings us full circle to what is most important in healthcare. Some argue that financial reform should rule the roost whereby providers do what they are paid to do. Others argue for training and education reform. But in the end, isn’t it the community, the patients who are most important? The system, however flawed it is, remains a fixture by which everyone receives their healthcare. Yes, we will do no harm; and yes, we will embrace innovation, but how we will do that in redesigning this system remains to be seen.
Isn’t it time to cross the chasm for healthcare? Isn’t it time we demand just a bit more? In doing so, healthcare will not fail, it already has.